Provider Demographics
NPI:1508459017
Name:STOUT, PAMELA LOUISE (RN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:LOUISE
Last Name:STOUT
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 PRAIRIE VIEW RD.
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401
Mailing Address - Country:US
Mailing Address - Phone:937-657-4046
Mailing Address - Fax:
Practice Address - Street 1:813 PRAIRIE VIEW RD.
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:937-657-4046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
L-34582174N00000X
OKR0132312163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No174N00000XOther Service ProvidersLactation Consultant, Non-RN